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^ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockto:�,, Calif. <br /> Telephone; (209) 466--6781 <br /> ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �J <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> f T,made <br /> (Complete In Triplicate) <br /> Application is herebto the San Joaquin Local Health District for a permit to construct <br /> and/or install the'work herein described'. This application is made in compliance with San'Joaquin <br /> County Ordinance' No. 1862 and the' Rules' and Regulations of thge,, San Joaquin. Local Health District. <br /> JOB ADDRESS/LOCATION ""NSUS TRACT <br /> Owner"s Name � • �j � � ._ Phone ' Ca <br /> City f <br /> Address .r.� <br /> " License #/� Phone <br /> Contractor's Name <br /> 1� TYPE OF WORK (Check) : NEW WELL DEEPEN: / RECONDITION /7 DESTRUCTION / <br /> PUMP INSTALLATION / '/ PUMP REPAIR / I PUMP REPLACEMENT <br /> Other / / <br /> k DISTANCE-TO-NEAREST-._ <br /> SEPTIC TANK IT PR <br /> 7j- SEWER-LINES-,-�•---�-=PIVY_= _.._-„r <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> M INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS <br /> f Industrial . Cable Tool Dia. -of Well Excavation I <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge -of. Casing ' <br /> Irrigation Gravel Pack Depth of, <br /> Grout -Seal -� r <br /> Other Rotary ; Type of out <br /> Other Other fnformatiori' <br /> PUMP INSTALLATION- Contractor �✓ -�-�✓��� O <br /> 'Type=of-.Ppum - - H.P. / <br /> PUMP REPLACEMENT: L&I State Work Don <br /> PUMP REPAIR: / / State Work Done. -== __� <br /> i <br /> ,DESTRUCTION OF WELL: Well Diameter �,. + Approximate Depth <br /> Describe Material and Procedure <br /> t � <br /> G I hereby agree to comply with all laws and tegulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> i WELL DRILLERS REPORT of the well and notify' them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ry (r� TITLE <br /> UL (DRAW PLOT. PLAN ON REVERSE SIDE <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B DATE -Z�2_ <br /> ADDITIONAL COMMENTS: f <br /> PHAS II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> n_ � <br /> -INSPECTION BY DATE l f� 6' � <br /> INSPECTION BY JQQ� DATE --� — <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E H 1426 ' <br /> .y, .. <br />